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Abnormal Uterine Bleeding
Abnormal Uterine Bleeding
Abnormal Uterine Bleeding
(AUB)
INA S. IRABON, MD, FPOGS, FPSRM, FPSGE
Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Reference:
1. Definition
2. Classification and Pathophysiology
3. Diagnosis
4. Treatment of acute and chronic AUB
Abnormal uterine bleeding (AUB)
Bleeding is abnormal/heavy
if:
it occurs at intervals of 21
days or less, or 35 days or
more;
Lasts longer than 7 days;
MBL of 80 mL or greater
Testing
100 1000
al blood loss (mL)
ratio of endogenous concentra -
prostaglandin E and menstrual Figure 26.6 Diagnostic approach to adults with abnormal uterine
endometrium; persistent endo - bleeding due to coagulopathy. (Data from Kouides PA, Conard J,
H, Kelly RW, et al. The synthesis Peyvandi F, et al. Hemostasis and menstruation: appropriate investi -
roliferative endometrium. JClin gation for underlying disorders of hemostasis in women with exces -
289.) sive menstrual bleeding. Fertil Steril. 2005;84[5]:1345-1351.)
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
CH ristocetin cofactor should be obtained
GershensontoDM,
rule outGM,
Lentz a coagula-
Valea FA editors; pp 621-633.
OVULATORY DYSFUNCTION (AUB-O)
the predominant cause of ovulatory
dysfunction postmenarchal and
premenopausal women is secondary to
alterations in neuroendocrine function.
there is continuous estradiol production
without corpus luteum formation and
progesterone production continuously
proliferating endometrium, which may
outgrow its blood supply necrosis.
uniform slough to the basalis layer does not
occur, which produces excessive uterine
bleeding.
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
OVULATORY DYSFUNCTION (AUB-O)
Anovulatory bleeding occurs most commonly during the
extremes of reproductive life: in the first few years after
menarche and during perimenopause.
In the adolescent: anovulation is due to an immaturity of the
hypothalamic-pituitary- ovarian (HPO) axis and failure of
positive feedback of estradiol to cause a luteinizing hormone
(LH) surge.
In the perimenopausal woman: lack of synchronization
between the components of the HPO axis occurs as the
woman approaches ovarian decline at menopause.
De Silva N. Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis. August 2016. www.uptodate.com
Physical Exam
Vital signs
tachycardia and hypotension
may signal acute hemodynamic
instability and the need for
rapid intervention
The presence of tachycardia,
pallor, or a heart murmur
suggests anemia
Rydz N and Jamieson MA. Managing heavy menstrual bleeding in adolescents. 2013. http://contemporaryobgyn.modernmedicine.com/
Physical Exam
Rydz N and Jamieson MA. Managing heavy menstrual bleeding in adolescents. 2013. http://contemporaryobgyn.modernmedicine.com/
Laboratory evaluation
Pregnancy test
Complete blood count including
differential and platelet count;
blood typing
Measure of iron stores
prothrombin time and activated
partial thromboplastin time
Bennet AR and Gray SH. What to do when she’s bleeding through: the recognition, evaluation, and
management of abnormal uterine bleeding in adolescents. Curr Opin Pediatr 2014, 26:413–419
Treatment
A. Adolescents:
after ruling out coagulation disorders, the main direction of
therapy is to temporize because once the HPO axis matures,
the problem will be corrected.
cyclic progestogen (medroxyprogesterone acetate, 10 mg
for 10 days each month for a few months) to produce
reliable and controlled menstrual cycles.
oral contraceptive (OC)may be an option if the problem
persist beyond 6 months.
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
ABNORMAL UTERINE BLEEDING: OVULATORY
DYSFUNCTION
B. Perimenopausal woman:
low-dose (20-μg) combined oral contraceptives( in a
nonsmoking woman).
Cyclic Progestogens
C. Reproductive-aged women:
chronic anovulatory bleeding is primarily caused by
hypothalamic dysfunction or PCOS.
Combined oral contraceptives
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
cyclic progestogens In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
ABNORMAL UTERINE BLEEDING:
ENDOMETRIAL